briefing nhs hospitals under pressure: trends in acute ... · 5 nhs hospitals under pressure:...

Paul Smith, Andy McKeon, Ian Blunt and Nigel EdwardsOctober 2014

Briefing

NHS hospitals underpressure: trends in acuteactivity up to 2022

Acute hospital care consumes almost half of the entire NHS budget.Access to a hospital bed is often seen as a critical indicator of howwell the NHS is running, yet the way we use hospital beds isconstantly changing. The demands on hospitals are thought to beinfluenced by a growing, ageing population with an increasingprevalence of chronic health problems, as well as changes in thetechnology used to diagnose and treat ill health.At the same time, government health policy is aimed at cutting thenumber of emergency and other admissions by providing more, betterservices outside of hospital. This is a major part of the rationale forthe government’s Better Care Fund, and a key metric of the policy.In this short paper, produced for the Financial Times, we have usedhistoric national data to look at trends in admissions and bed use overthe last few years, and have used population projections to explorethe likely pressures on hospitals in the future.

2 NHS hospitals under pressure: trends in acute activity up to 2022

Key points The total number of hospital admissions in England grew from 12.6 million in 2006/07 to 14.6 million

in 2012/13; an increase of 16%. While some of this increase was driven by our expanding and ageingpopulation, there were 60% more hospital admissions than population change would have implied.

If admission rates continue to increase, the growing and ageing population alone means that theNHS will need at least an additional 6.2 million bed days (overnight stays) by 2022. This is equivalentto approximately 17,000 beds, which equates to about 22 hospitals with 800 beds each.

This increased pressure is an important component of the funding gap facing the NHS. Weestimate the need for such substantial additional productivity may amount to around a quarter ofthe £30 billion gap facing the NHS by 2022.

Even if extra money was available, building 22 more hospitals would not be a good decision. Thesystem is ‘running hot’. Yet more hospitals are not the answer.

To date, attempts to reduce the numbers of people admitted to hospital through better preventivecare in their communities have not been very successful on a large scale. A more certain strategyto meet this challenge would be to concentrate on ensuring that patients can be discharged quicklyand do not stay in hospital for long periods – an approach that we know has worked in the past.

Our analysis of the last seven years shows us that despite rising admissions, the number of generaland acute beds available in NHS hospitals fell from 126,976 in 2006 to 106,374 in 2013. The extraadmissions have been accommodated by reducing the length of time patients stay overnight in ahospital bed – so-called bed days – and through increased bed occupancy, which rose from 85.3%in 2006/07 to 89.8% in 2012/13.

The total number of bed days in the NHS stayed largely the same over the period 2006–2013. This wasachieved both by increased shifts of activity to day or short-stay cases – very often associated withinvestigative procedures such as scans – and a reduction in the numbers of people staying over 28 daysin hospital.

The story of the last seven years shows us that significant reductions in lengths of stay can beachieved: between 2006 and 2013, lengths of stay for those in hospital for over a month werereduced by 13%. But the future challenge is even greater.

It is therefore clear that more significant change in the way care is delivered is needed to copewith the considerable pressures on acute hospitals. Such change will require the NHS to makethree key changes:

o Make increasing use of services specifically designed for patients who only need to stay inhospital for a few hours rather than longer inpatient stays, such as further initiatives to expandday-care elective surgery.

o Substantially improve the way that all departments (and services outside the hospital) worktogether to ensure patients do not stay in hospital any longer than they absolutely need to, forexample by improving discharge arrangements.

o Widen the range of alternative intermediate services available in community or social care;including making use of beds in nursing homes, hotels or indeed patients’ own homes.


BackgroundIt is now well established that the NHS is currently experiencing the dual challenges of anunprecedented period of constrained funding and an apparently ever-increasing demand for services.We are seeing an ageing and growing population, an increasing number of people with long-termchronic conditions such as diabetes, and evolving health technology.

Many commentators have suggested that NHS services require significant structural change if theyare to meet these challenges. One area that has received much attention is the idea that we shouldrely less on hospitals and more on preventive and community-based services in the future.

These pressures are not new – hospital admissions have been increasing steadily for at least the lastdecade. How the NHS has met these pressures in the recent past gives an indication of how it might farein the future. At the very least, it offers a benchmark against which plans and progress can be judged.

This report therefore reviews trends in acute hospital activity (inpatients and day cases) for the period2006/07 to 2012/13, using hospital episode statistics data, and forecasts what demand may be to2021/22 based on recent trends and demographic pressure (using Office for National Statisticspopulation data). It also considers the implications of these trends and forecasts for hospitals.

The date of 2006 was chosen as it pre-dates the current period of austerity and therefore allows us toassess the trend over this period of time. We used 2012/13 as the cut-off date for reviewing pasttrends as only provisional figures for 2013/14 were available at the time of analysis.

In 2012/13, the NHS in England spent £47 billion on care in acute hospitals, which equates to 48%of its entire budget. Most patients are ‘admitted’ for less than a day, either for day-case surgery or foran investigative procedure. Those that are admitted overnight or longer may be in a minority, butthey are also the most costly.

In 2012/13, there were over 14.6 million hospital admissions. Though the vast majority of inpatientsstay for less than seven days, a small minority (about 1.5%) can be in hospital for more than 28 days.In total, patients spent 37.9 million bed days in acute NHS hospitals in 2012/13. Those staying 28days or longer used around a third of all bed days.

How have the numbers of admissions changed since 2006?NHS acute hospitals reported increased admissions over the period 2006/07 to 2012/13, from12.6 million per year to 14.6 million per year; an increase of 16%.

We know that older people are more likely to be admitted to hospital, and that the numbers ofolder people in the population are increasing (Figure 1). But as Figure 2 shows, activity rose about60% more than would be expected given the increase in the age and size of the population duringthis period.


NHS acute hospitals have also seen increasing numbers of emergency admissions of(disproportionately elderly) people; accounting for about a quarter of the increase in overall activity.This has been the source of much concern and is a focus for both policy-makers and managementactivity on the ground. Reducing the number of emergency admissions has been an objective forsome time. Health and Wellbeing Boards (HWBs) are now expected to plan for at least a 3.5%reduction in 2015/16 under the government’s Better Care Fund.

Increasing hospital activity has been a source of pressure on hospital and clinical commissioninggroup (CCG) finances. Acute hospitals have continued to take the lion’s share of any growth in CCG(and before them, primary care trust) allocations, with other services such as primary care and mentalhealth suffering accordingly. Even so, hospital finances have deteriorated, with increasing numbers oftrusts in deficit (Lafond and others, 2014).

How have the types of admissions changed since 2006?As Figure 3 demonstrates, two thirds of the overall increase in hospital admissions has been in shortstays for investigations and diagnosis, and day cases – so-called elective same day admissions.

Improvements in technology have made new forms of diagnostic procedure more accessible. Forexample, there were nearly 330,000 more CT scans of the head in 2012 than in 2006, and a similargrowth in diagnostic endoscopies. It has also enabled patients who previously would have beenadmitted overnight for surgery to be treated as day cases.

There have also been increasing numbers of emergency (non-elective) cases admitted for less thanone day, which reflects changing medical practice (Cooke and others, 2003). In some trusts there is


also evidence that the increase in zero-day admissions is related to efforts to achieve the maximumfour-hour wait target in accident and emergency (A&E) (Blunt and others, 2010).

Looking specifically at overnight admissions (people staying in hospital one night or more), it appearsthat growth in this activity has no more than kept pace with demographic pressure. The additionalactivity overall has therefore been driven largely by day-case admissions.

Though overall admissions have increased, there were some surgical treatments that declined inactivity, for example: 8,000 (46%) fewer vasectomies, which could be explained by these proceduresnow being largely conducted in community settings; 32,000 (80%) fewer varicose vein operations;and 9,000 (11%) fewer tonsillectomies. But this is counterbalanced by significant growth elsewhere,for example 39,000 (14%) additional cataract operations.

This shift is likely to be due to changing priorities as determined by the National Institute for Healthand Care Excellence (NICE), and commissioners seeking to reduce the numbers of ‘low priority’treatments. The growth in cataract surgery is likely to be a response both to the ageing populationand the need to reduce waiting times.

NHS contracts with the private sector have taken some of the load from traditional NHS hospitals,but this still only makes a small contribution. Non-NHS providers accounted for just 2.5% of NHSinpatient activity in 2012/13, and concentrated on minor surgical and diagnostic cases, where theygenerally undertook 10% or less of any one procedure. The private sector did, however, make a muchlarger contribution to hip and knee replacements, accounting for about 20% of NHS activity.

How has bed use changed since 2006?Though admissions increased during this period, the average length of time patients stayed in hospitalfell – suggesting that hospitals have become more productive. As Figure 4 shows, the number of beddays fell by just over 3% between 2006/07 and 2012/13, despite the increases in activity. The totalnumber of bed days used was lower than would be expected given the increase in the age and size ofthe population during this period.

This greater productivity has come from two main sources. First, as noted above, there was acontinuing move to treat more elective inpatients as day cases. This is part of a long-term trend –indeed the number of elective inpatient admissions staying overnight fell by 202,845 (14%) over theperiod, whereas day cases rose by 1,364,421; an increase of 30% (Figure 3).

Second, there were significant reductions in the number of bed days concentrated in longer-stayingpatients – those staying over 28 days (Figure 5). There has been little change in the total number ofbed days for those staying less than 28 days. Small reductions in the number of such long-stayingpatients can have a large impact on bed days as they account for only 1.5% of admissions, but nearly30% of all bed days. For many of these patients, a key factor influencing their discharge will be theavailability of alternative care – either in another institution or support for them at home.


There was a net reduction of 1.4 million bed days for elective admissions (Figure 6a), concentratedmainly in those patients staying longer than one night in hospital.

For emergency admissions, reductions in the number of people staying over 28 days released 1.5million bed days. However, this was offset by increases in the number of bed days for patients stayingfor shorter periods, leading to a net increase of 48,000 emergency bed days (Figure 6b).


Across all types of hospital admission there was a net reduction of 1.3 million bed days.

It seems that capacity released by the decline in the number of emergency patients staying over28 days has been taken up with increased emergency admissions, albeit for people with shorterlengths of stay. The overall net reduction in bed days has largely been the result of the substitution


of day-case activity for inpatient care for some elective patients. But these changes have meant thatthe NHS has not had to add to its bed stock, but is using it more productively.

Are these trends likely to continue?In both emergency and elective care, admissions have risen year-on-year. However, there are signsthat the rate of growth in activity and the reductions in length of stay are slowing. Since 2008/09 theannual growth rate in overall activity has steadily slowed from 4.5% at the start of the period, to 0.6%in 2012/13 (Figure 7). Provisional data for 2013/14 suggest activity continued to grow at a little lessthan 1%.

The growth in emergency admissions slowed more or less steadily from 5.7% between 2007/08 and2008/09, to 1.9% between 2011/12 and 2012/13. The rate of elective cases has been more volatile,but even so, growth in the second half of the period was lower than the first. This perhaps suggeststhat either austerity has had an impact and lower growth in elective cases is now being reflected inlonger waiting times, or that the early part of the period reflected a big increase in consultantappointments that has now levelled off.

Reductions in length of stay slowed in 2011/12 and ceased in 2012/13 (Figure 8). This would beparticularly concerning if it became a trend.


Getting patients discharged from hospital requires the right facilities to be available in thecommunity. However, adult social services have suffered cuts of 15% in real terms between 2009/10and 2012/13 (Ismail and others, 2014). The 2013 National Intermediate Care Audit also reportedsignificant variability of services and little progress or investment (NHS Benchmarking Network,2013). Failure to further reduce length of stay also puts extra pressure on hospital finances – and maybe one cause of their deterioration – and affects performance in A&E where the inability to dischargepatients who are already in hospital sufficiently quickly has been a factor in lengthening the timepatients spend in A&E (Blunt, 2014).

What does this mean for the future?It is estimated that between 2012/13 and 2021/22, the number of people aged 65 and over willincrease by 20%, and the number over 85, who have the highest rates of individual service use, willincrease by 33%. The NHS will need to at least keep pace with this future demographic pressure.

If admission rates continue to rise, the growing and ageing population alone will result in the need foran additional 6.2 million bed days (a 16% increase on current provision) (Figure 9). This is equivalentto approximately 17,000 beds, or about 22 hospitals of 800 beds each.

This increase in activity makes up an important component of the funding gap facing the NHS.Using a rough estimate based on the national tariff, we estimate it may amount to around a quarter ofthe £30 billion gap facing the NHS by 2022 (Roberts and others, 2012). However, even if the extrainvestment in bed stock was available, it would not be desirable from either a patient care or a systemmanagement point of view to build additional hospitals. The best way to manage care for people withcomplex and multiple conditions is often outside of hospital – either through preventing people fromentering hospital in the first place or speeding up their discharge from hospital into the community.


Current policy is aimed at cutting the number of emergency admissions by providing more, betterservices outside hospital that can either prevent the need for hospital admission or offer the samecare but in different settings. This is a common theme in initiatives for more integrated services,including the government’s Better Care Fund. But there is little evidence that this can be achieved(Bardsley and others, 2013).

Continuing to reduce length of stay may be a better option for improving efficiency and keeping theacute sector solvent. Unlike reducing admissions – which requires the NHS to prevent manypotential patients, some of whom will be unknown, from entering the hospital system – patients withlong lengths of stay are already in hospital and are therefore clearly identifiable. It is clear that it canbe done. As we have shown, the NHS has shown continued progress in cutting long lengths of stayover the last seven years: a 16% rise in admissions was largely managed by changes in the types ofprocedures offered and reductions in lengths of stay, particularly for those staying over a month.

As noted above, the reward for the effort could also be high – only 1.5% of people stay in hospitalfor longer than 28 days, but they account for nearly 30% of all bed days.

But it would mean the NHS upping its game. If the rates of admission for each age group stayroughly the same, the effects of an ageing population will result in an average annual growth rate inbed days of 1.7% between 2012/13 and 2021/22, compared with the 1.4% that was predicted overthe previous seven years – an increase of a quarter.

There may also be other pressures from new treatments, new technologies and new publicexpectations. These have in the past contributed towards the increase in costs or demand, but are notfactored into this analysis. Past improvements in productivity are partially linked with greater use ofless costly day care and diagnostics. It is unclear how far we can expect this to continue. Even if this


can be achieved, there is evidence that increasing the availability of beds increases the number ofadmissions (Shain and Roemer, 1959).

For the longer-stay cases, continuing to reduce bed occupancy in acute hospitals may still be possible:cutting lengths of stay by a quarter for those staying over two weeks would create the 6.2 million beddays needed to meet demographic pressure. In practice, these savings are likely to come from a rangeof measures:

First, the NHS will need to make increasing use of services specifically designed for patients whoonly need to stay in hospital for a few hours rather than longer inpatient stays, such as furtherinitiatives to expand day-care elective surgery.

Second, the NHS will need to substantially improve the way that all departments (and servicesoutside the hospital) work together to ensure patients do not stay in hospital any longer than theyabsolutely need to, for example by improving discharge arrangements.

Third, and perhaps most importantly, the range of intermediate services available in community orsocial care will need to widen. The effect of this will be to absorb the demand for extra hospitalbeds through extra beds provided elsewhere – these may be provided in nursing homes, hotels,care homes or indeed in patients’ own homes, with specialist services delivered by doctors andnurses in the community.

This can only be achieved if there is greater investment in intermediate and social care, and othercommunity services, so increased numbers of long-stay patients can be discharged more quickly ifthis is appropriate for them.

The challenge is great, but it is one that the NHS must rise to if we are not to be faced with ever-growing pressures on the hospital sector.


ReferencesBardsley M, Steventon A, Smith J and Dixon J (2013) Evaluating Integrated and Community-based Care.Nuffield Trust.

Blunt I (2014) Focus On: A&E Attendances. Why are patients waiting longer? The Health Foundation andNuffield Trust.

Blunt I, Bardsley M and Dixon J (2010) Trends in Emergency Admissions in England 2004–2009: Is greaterefficiency breeding inefficiency? Nuffield Trust.

Cooke MW, Higgins J and Kidd P (2003) ‘Use of emergency observation and assessment wards: asystematic literature review’, Emergency Medicine, 20, 138–42.

Ismail S, Thorlby R and Holder H (2014) Focus On: Social Care for Older People. Reductions in adult socialservices for older people in England. The Health Foundation and Nuffield Trust.

Lafond S, Arora S, Charlesworth A and McKeon A (2014) Into the Red? The State of the NHS’ Finances:An analysis of NHS expenditure between 2010 and 2014. Nuffield Trust.

NHS Benchmarking Network (2013) National Audit of Intermediate Care Report 2013.

Roberts A, Marshall L and Charlesworth A (2012) A Decade of Austerity? The funding pressures facing theNHS in England 2011/12 to 2021/22. Nuffield Trust.

Shain M and Roemer MI (1959) ‘Hospital costs relate to the supply of beds’, Modern Hospital,92(4), 71–3.


About this paperThis independent research was conducted by the Nuffield Trust for the Financial Times.

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